61 results on '"Alnsasra H"'
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2. Sex differences among patients with tachyarrhythmias and bradyarrhythmias following acute myocardial infarction
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Alnsasra, H, primary, Tsaban, G, additional, Cooper, J, additional, and Haim, M, additional
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- 2022
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3. Chronic amiodarone therapy and mortality among atrial fibrillation patients; insights from a real-life contemporary population
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Tsaban, G, primary, Gordon, M, additional, Omari, Y, additional, Kezerle, L, additional, Alnsasra, H, additional, Buturlin, K, additional, Bareza, S, additional, Wagshal, A, additional, Novack, V, additional, Konstantino, Y, additional, and Haim, M, additional
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- 2022
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4. Amiodarone therapy and risk of primary lung cancer; insights from a real-life contemporary population study
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Tsaban, G, primary, Gordon, M, additional, Omari, Y, additional, Kezerle, L, additional, Alnsasra, H, additional, Buturlin, K, additional, Bareza, S, additional, Wagshal, A, additional, Novack, V, additional, Konnstantino, Y, additional, and Haim, M, additional
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- 2022
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5. Amiodarone and lung toxicity in a real-life contemporary population
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Tsaban, G, primary, Gordon, M, additional, Omari, Y, additional, Kezerle, L, additional, Alnsasra, H, additional, Buturlin, K, additional, Bareza, S, additional, Wagshal, A, additional, Konnstantino, Y, additional, Novack, V, additional, and Haim, M, additional
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- 2022
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6. Colchicine for secondary prevention of cardiovascular disease, a cost per outcome analysis
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Tsaban, G, primary, Alnsasra, H, additional, El Nasasra, A, additional, Aboalhasan, E, additional, Azuri, J, additional, Hammerman, A, additional, and Arbel, R, additional
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- 2022
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7. Sacubitril/valsartan versus in empagliflozin heart failure with preserved ejection fraction
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Alnsasra, H, primary, Tsaban, G, additional, Aboalhasan, E, additional, El Nasasra, A, additional, Azuri, J, additional, Hammerman, A, additional, and Arbel, R, additional
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- 2022
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8. The Impact of Sirolimus as a Primary Immunosuppressant on Myocardial Fibrosis and Diastolic Function Following Heart Transplantation
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Alnsasra, H., primary, Asleh, R., additional, Oh, J.K., additional, Maleszewski, J.J., additional, Lerman, A., additional, Toya, T., additional, Chandrasekaran, K., additional, Bois, M.C., additional, and Kushwaha, S.S., additional
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- 2021
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9. Incidence, Predictors and Outcomes of Stroke Following Cardiac Transplantation
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Alnsasra, H., primary, Asleh, R., additional, Kumar, N., additional, Toya, T., additional, Lopez, C., additional, Kremers, W.K., additional, Edwards, B., additional, Daly, R.C., additional, and Kushwaha, S.S., additional
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- 2021
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10. Utilization of cardiac MRI for the assessment of suspected rejection with negative biopsy in heart transplant recipients
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Anand, S, primary, Young, P, additional, Alnsasra, H, additional, Shrivastava, S, additional, Asleh, R, additional, Murphy, K, additional, Smith, B, additional, Kremers, W, additional, Kushwaha, S, additional, Clavell, A, additional, Steidley, D.E, additional, Pereira, N, additional, and Lemond, L.M, additional
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- 2020
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11. Long-Term Sirolimus for Primary Immunosuppression and Incidence of De Novo Malignancy Following Heart Transplantation
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Asleh, R., primary, Li, X., additional, Alnsasra, H., additional, Briasoulis, A., additional, Smith, B., additional, Kremers, W., additional, Pereira, N.L., additional, Edwards, B.S., additional, Daly, R.C., additional, Stulak, J.M., additional, Clavell, A., additional, and Kushwaha, S.S., additional
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- 2019
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12. Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation with Continuous Flow Left Ventricular Assist Devices
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Asleh, R., primary, Alnsasra, H., additional, Schettle, S.D., additional, Taher, R., additional, Dunlay, S.M., additional, Stulak, J.M., additional, Daly, R.C., additional, Behfar, A., additional, Pereira, N.L., additional, Clavell, A.L., additional, Multais, S., additional, Frantz, R.P., additional, and Kushwaha, S.S., additional
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- 2019
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13. Cardiac magnetic resonance imaging in heart transplant recipients with biopsy-negative graft dysfunction.
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Anand S, Alnsasra H, LeMond LM, Shrivastava S, Asleh R, Rosenbaum A, Kobrossi S, Mohananey A, Murphy K, Smith BH, Kushwaha S, Steidley DE, Clavell A, Young P, and Pereira NL
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- Humans, Male, Female, Middle Aged, Biopsy, Retrospective Studies, Myocardium pathology, Stroke Volume physiology, Follow-Up Studies, Ventricular Function, Left physiology, Adult, Heart Transplantation adverse effects, Magnetic Resonance Imaging, Cine methods, Graft Rejection diagnosis, Graft Rejection diagnostic imaging
- Abstract
Aims: Graft dysfunction (GD) after heart transplantation (HTx) can develop without evidence of cell- or antibody-mediated rejection. Cardiac magnetic resonance imaging (CMR) has an evolving role in detecting rejection; however, its role in biopsy-negative GD has not been described. This study examines CMR findings, evaluates outcomes based on CMR results, and seeks to identify the possibility of rejection missed through endomyocardial biopsy by using CMR in HTx recipients with biopsy-negative GD., Methods and Results: HTx recipients with GD [defined as a decrease in left ventricular ejection fraction (LVEF) by >5% and LVEF < 50%] in the absence of rejection by biopsy or allograft vasculopathy and who underwent CMR were included in the study. The primary outcome was a composite of all-cause mortality, re-transplantation, or persistent LVEF < 50%. Overall, 34 HTx recipients developed biopsy-negative GD and underwent CMR. Left ventricular late gadolinium enhancement (LGE) on CMR was observed in 16 patients with two distinct patterns: diffuse epicardial (n = 13) and patchy (n = 3) patterns. Patients with LGE developed GD later after HTx [4 (1.4-6.8) vs. 0.8 (0.3-1.2) years, P < 0.001], were more often symptomatic (88% vs. 56%, P = 0.06), and had greater haemodynamic derangement (pulmonary capillary wedge pressure: 19 ± 7 vs. 13 ± 3 mmHg, P = 0.002) as compared with those without LGE. No significant difference was observed in the primary composite outcome between patients with LGE and those without LGE (50% vs. 38% of patients with events, P = 0.515). During a median follow-up of 3.8 years, mean LVEF improved similarly in the LGE-negative (37-55%) and LGE-positive groups (32-55%) (P = 0.16)., Conclusions: Biopsy-negative GD occurs with and without LGE when assessed by CMR, indicative of possible rejection/inflammation occurring only in a subset of patients. Irrespective of LGE, LVEF improvement occurs in most GD patients, suggesting that other neurohormonal or immunomodulatory mechanisms may also contribute to GD development., (© 2024 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)
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- 2024
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14. Dapagliflozin versus sacubitril-valsartan for heart failure with mildly reduced or preserved ejection fraction.
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Arbel R, Azab AN, Oberoi M, Aboalhasan E, Star A, Elhaj K, Khalil F, and Alnsasra H
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Background and Aim: Heart failure with preserved ejection fraction (HFpEF) is associated with an increased risk of heart failure (HF) hospitalizations and cardiovascular death (CVD). Both dapagliflozin and sacubitril-valsartan have recently shown convincing reductions in the combined risk of CVD and HF hospitalizations in patients with HF and mildly reduced ejection fraction (HFmrEF) or HFpEF. We aimed to investigate the cost-per-outcome implications of dapagliflozin vs sacubitril-valsartan in the treatment of HFmrEF or HFpEF patients., Methods: We compared the annualized cost needed to treat (CNT) to prevent the composite outcome of total HF hospitalizations and CVD with dapagliflozin or sacubitril-valsartan. The CNT was estimated by multiplying the annualized number needed to treat (aNNT) by the annual cost of therapy. The aNNT was calculated based on data collected from the DELIVER trial for dapagliflozin and a pooled analysis of the PARAGLIDE-HF and PARAGON-HF trials for sacubitril-valsartan. Costs were based on 2022 US prices. Scenario analyses were performed to attenuate the differences in the studies' populations., Results: The aNNT with dapagliflozin in DELIVER was 30 (95% confidence interval [CI]: 21-62) versus 44 (95% CI: 25-311) with sacubitril-valsartan in a pooled analysis of PARAGLIDE-HF and PARAGON-HF, with an annual cost of $4,951 and $5,576, respectively. The corresponding CNTs were $148,547.13 (95% CI: $103,982.99-$306,997.39) for dapagliflozin and $245,346.77 (95% CI: $139,401.58-1,734,155.60) for sacubitril-valsartan for preventing the composite outcome of CVD and HF hospitalizations. The CNT for preventing all-cause mortality was lower for dapagliflozin than sacubitril-valsartan $1,128,958.15 [CI: $401,077.24-∞] vs $2,185,816.71 [CI: $607,790.87-∞]., Conclusion: Dapagliflozin provides a better monetary value than sacubitril-valsartan in preventing the composite outcome of total HF hospitalizations and CVD among patients with HFmrEF or HFpEF., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Arbel, Azab, Oberoi, Aboalhasan, Star, Elhaj, Khalil and Alnsasra.)
- Published
- 2024
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15. Reversibility of precapillary pulmonary hypertension and outcomes after heart transplantation bridged with left ventricular assist devices: Insight from the United Network for Organ Sharing.
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Alnsasra H, Perue RK, Khalil F, Regev O, Kushwaha SS, Briasoulis A, and Asleh R
- Abstract
Background: In light of the updated lowered threshold for diagnosing pulmonary hypertension (PH), the reversibility of precapillary PH with left ventricular assist device (LVAD) and the associated post-heart transplantation (HT) outcomes remain unclear., Methods: Using data from the United Network for Organ Sharing database, we aimed to investigate predictors of persistent precapillary PH in HT recipients bridged with LVAD and examine the interrelated post-HT survival using the updated pulmonary vascular resistance (PVR) cutoff of >2 Wood units for precapillary PH., Results: Among 2169 HT recipients bridged with LVAD, 1299 had PVR >2 at baseline; 551 (42.4%) of whom normalized their PVR ≤2 and 748 (57.6%) remained with elevated PVR >2 after LVAD implantation. Female sex (adjusted odds ratio [aOR]; 2.22, 95% confidence interval [CI], 1.61-3.07; P < .001) and inotrope treatment at listing (aOR, 1.31; 95% CI, 1.03-1.66; P = .028) were associated with persistently elevated PVR after LVAD. Conversely, longer duration of LVAD support (aOR, 0.74; 95% CI, 0.65-0.84; P < .001) and use of HeartMate II (aOR, 0.74; CI, 0.59-0.93; P = .011) were found to be protective against persistently elevated PVR after LVAD. Persistently elevated PVR >2 after LVAD was associated with increased risk of death compared with those who normalized their PVR (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.01-1.57; P = .037). However, the normalized PVR post-LVAD group had comparable survival with those with PVR ≤2 at baseline (aHR, 0.76; 95% CI, 0.57-1.02; P = .07)., Conclusions: Many recipients of HT bridged with LVAD remain with PVR >2 after LVAD implantation, which is associated with increased risk of death after HT compared with patients with normalized PVR after LVAD., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)
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- 2024
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16. Amiodarone and pulmonary toxicity in atrial fibrillation: a nationwide Israeli study.
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Tsaban G, Ostrovsky D, Alnsasra H, Burrack N, Gordon M, Babayev AS, Omari Y, Kezerle L, Shamia D, Bereza S, Konstantino Y, and Haim M
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- Humans, Female, Aged, Male, Anti-Arrhythmia Agents adverse effects, Israel epidemiology, Amiodarone, Atrial Fibrillation drug therapy, Atrial Fibrillation epidemiology, Lung Diseases, Interstitial, Lung Neoplasms drug therapy
- Abstract
Background and Aims: Amiodarone-related interstitial lung disease (ILD) is the most severe adverse effect of amiodarone treatment. Most data on amiodarone-related ILD are derived from periods when amiodarone was given at higher doses than currently used., Methods: A nationwide population-based study was conducted among patients with incident atrial fibrillation (AF) between 1 December 1999 and 31 December 31 2021. Amiodarone-exposed patients were matched 1:1 with controls unexposed to amiodarone based on age, sex, ethnicity, and AF diagnosis duration. The final patient cohort included only matched pairs where amiodarone therapy was consistent throughout follow-up. Directed acyclic graphs and inverse probability treatment weighting (IPTW) modelling were used. Patients with either prior ILD or primary lung cancer (PLC) were excluded. The primary outcome was the incidence of any ILD. Secondary endpoints were death and PLC., Results: The final cohort included 6039 amiodarone-exposed patients who were matched with unexposed controls. The median age was 73.3 years, and 51.6% were women. After a mean follow-up of 4.2 years, ILD occurred in 242 (2.0%) patients. After IPTW, amiodarone exposure was not significantly associated with ILD [hazard ratio (HR): 1.45, 95% confidence interval (CI): 0.97, 2.44, P = 0.09]. There was a trivial higher relative risk of ILD among amiodarone-exposed patients between Years 2 and 8 of follow-up [maximal risk ratio (RR): 1.019]. Primary lung cancer occurred in 97 (0.8%) patients. After IPTW, amiodarone was not associated with PLC (HR: 1.18, 95% CI: 0.76, 2.08, P = 0.53). All-cause death occurred in 2185 (18.1%) patients. After IPTW, amiodarone was associated with reduced mortality risk (HR: 0.65, 95% CI: 0.60, 0.72, P < 0.001). The results were consistent across a variety of sensitivity analyses., Conclusion: In a contemporary AF population, low-dose amiodarone was associated with a trend towards increased risk of ILD (15%-45%) but a clinically negligible change in absolute risk (maximum of 1.8%), no increased risk of PLC, and a lower risk of all-cause mortality., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)
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- 2024
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17. Perimyocarditis Associated with Immune Checkpoint Inhibitors: A Case Report and Review of the Literature.
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Shalata W, Steckbeck R, Abu Salman A, Abu Saleh O, Abu Jama A, Attal ZG, Shalata S, Alnsasra H, and Yakobson A
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- Humans, Female, Aged, Nivolumab adverse effects, Immune Checkpoint Inhibitors, Ipilimumab adverse effects, Antineoplastic Agents, Immunological adverse effects, Carcinoma, Non-Small-Cell Lung drug therapy, Lung Neoplasms drug therapy
- Abstract
Patient prognoses have been significantly enhanced by immune checkpoint inhibitors (ICIs), altering the standard of care in cancer treatment. These novel antibodies have become a mainstay of care for metastatic non-small-cell lung cancer (mNSCLC) patients. Several types of adverse events related to ICIs have been identified and documented as a result of the launch of these innovative medicines. We present here a 74-year-old female patient with a stage IV lung adenocarcinoma, treated with nivolumab plus ipilimumab, who developed perimyocarditis two weeks after receiving the third cycle of immune checkpoint inhibitor therapy. The patient was diagnosed using troponin levels, computed tomography (CT) angiography, and echocardiography. After hospitalization, her cardiac condition was successfully resolved with corticosteroids, colchicine, and symptomatic treatment. To the best of our knowledge, this is one of the rarest cases to be reported of perimyocarditis as a toxicity of immunotherapy in a patient treated for adenocarcinoma of the lung.
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- 2024
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18. Sex differences in ventricular arrhythmia, atrial fibrillation and atrioventricular block complicating acute myocardial infarction.
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Alnsasra H, Tsaban G, Weinstein JM, Nasasra M, Ovdat T, Beigel R, Orvin K, and Haim M
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Background: Acute myocardial infarction (AMI) complicated by tachyarrhythmias or high-grade atrioventricular block (HAVB) may lead to increased mortality., Purpose: To evaluate the sex differences in patients with AMI complicated by tachyarrhythmias and HAVB and their associated outcomes., Materials and Methods: We analyzed the incidence rates of arrhythmias following AMI from the Acute Coronary Syndrome Israeli Survey database from 2000 to 2018. We assessed the differences in arrhythmias incidence and the associated mortality risk between men and women., Results: This cohort of 14,280 consecutive patients included 3,159 (22.1%) women and 11,121 (77.9%) men. Women were less likely to experience early ventricular tachyarrhythmia (VTA), (1.6% vs. 2.3%, p = 0.034), but had similar rates of late VTA (2.3% vs. 2.2%, p = 0.62). Women were more likely to experience atrial fibrillation (AF) (8.6% vs. 5.0%, p < 0.001) and HAVB (3.7% vs. 2.3%, p < 0.001). The risk of early VTAs was similar in men and women [adjusted Odds Ratio (aOR) = 0.76, p = 0.09], but women had a higher risk of AF (aOR = 1.27, p = 0.004) and HAVB (aOR = 1.30, p = 0.03). Early [adjusted hazard ratio (aHR) = 2.84, p < 0.001] and late VTA (aHR =- 4.59, p < 0.001), AF (aHR = 1.52, p < 0.001) and HAVB (aHR = 2.83, p < 0.001) were associated with increased 30-day mortality. Only late VTA (aHR = 2.14, p < 0.001) and AF (aHR = 1.44, p = 0.002) remained significant in the post 30 days period., Conclusions: During AMI women experienced more AF and HAVB but fewer early VTAs than men. Early and late VTAs, AF, and HAVB were associated with increased 30-day mortality. Only late VTA and AF were associated with increased post-30-day mortality., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Alnsasra, Tsaban, Weinstein, Nasasra, Ovdat, Beigel, Orvin and Haim.)
- Published
- 2023
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19. Dapagliflozin versus empagliflozin in patients with chronic kidney disease.
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Alnsasra H, Tsaban G, Solomon A, Khalil F, Aboalhasan E, Azab AN, Azuri J, Hammerman A, and Arbel R
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Background and Aim: Dapagliflozin and empagliflozin have demonstrated favorable clinical outcomes among patients with chronic kidney disease (CKD). However, their comparative monetary value for improving outcomes in CKD patients is unestablished. We examined the cost-per-outcome implications of utilizing dapagliflozin as compared to empagliflozin for prevention of renal and cardiovascular events in CKD patients. Methods: For calculation of preventable events we divided the allocated budget by the cost needed to treat (CNT) for preventing a single renal or cardiovascular event. CNT was derived by multiplying the annualized number needed to treat (aNNT) by the annual therapy cost. The aNNTs were determined based on data from the DAPA-CKD and EMPEROR-KIDNEY trials. The budget limit was defined based on the threshold recommended by the United States' Institute for Clinical and Economic Review. Results: The aNNT was 42 both dapagliflozin (95% confidence interval [CI]: 34-59) and empagliflozin (CI: 33-66). The CNT estimates for the prevention of one primary event for dapagliflozin and empagliflozin were comparable at $201,911 (CI: $163,452-$283,636) and $209,664 (CI: $164,736-$329,472), respectively. However, diabetic patients had a higher CNT with dapagliflozin ($201,911 [CI: $153,837-$346,133]) than empagliflozin ($134,784 [CI: $109,824-$214,656]), whereas non-diabetic patients had lower CNT for dapagliflozin ($197,103 [CI: $149,029-$346,133]) than empagliflozin ($394,368 [CI: $219,648-$7,093,632]). The CNT for preventing CKD progression was higher for dapagliflozin ($427,858 [CI: $307,673-$855,717]) than empagliflozin ($224,640 [CI: $169,728-$344,448]). For preventing cardiovascular death (CVD), the CNT was lower for dapagliflozin ($1,634,515 [CI: $740,339-∞]) than empagliflozin ($2,990,208 [CI: $1,193,088-∞]). Conclusion: Among patients with CKD, empagliflozin provides a better monetary value for preventing the composite renal and cardiovascular events in diabetic patients while dapagliflozin has a better value for non-diabetic patients. Dapagliflozin provides a better monetary value for the prevention of CVD, whereas empagliflozin has a better value for the prevention of CKD progression., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Alnsasra, Tsaban, Solomon, Khalil, Aboalhasan, Azab, Azuri, Hammerman and Arbel.)
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- 2023
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20. Depression among Patients with an Implanted Left Ventricular Assist Device: Uncovering Pathophysiological Mechanisms and Implications for Patient Care.
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Alnsasra H, Khalil F, Kanneganti Perue R, and Azab AN
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- Humans, Depression etiology, Treatment Outcome, Tissue Donors, Patient Care adverse effects, Retrospective Studies, Heart-Assist Devices adverse effects, Heart Transplantation adverse effects, Heart Failure
- Abstract
Depression is a common and devastating mental illness associated with increased morbidity and mortality, partially due to elevated rates of suicidal attempts and death. Select patients with end-stage heart failure on a waiting-list for a donor heart undergo left ventricular assist device (LVAD) implantation. The LVAD provides a circulatory flow of oxygenated blood to the body, mimicking heart functionality by operating on a mechanical technique. LVAD improves functional capacity and survivability among patients with end-stage heart failure. However, accumulating data suggests that LVAD recipients suffer from an increased incidence of depression and suicide attempts. There is scarce knowledge regarding the pathological mechanism and appropriate treatment approach for depressed LVAD patients. This article summarizes the current evidence on the association between LVAD implantation and occurrence of depression, suggesting possible pathological mechanisms underlying the device-associated depression and reviewing the current treatment strategies. The summarized data underscores the need for a rigorous pre-(LVAD)-implantation psychiatric evaluation, continued post-implantation mental health assessment, and administration of antidepressant treatment as necessary.
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- 2023
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21. Cardiac Transplantation: Physiology and Natural History of the Transplanted Heart.
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Asleh R, Alnsasra H, Villavicencio MA, Daly RC, and Kushwaha SS
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- Humans, Heart Failure surgery, Heart Diseases epidemiology, Graft Rejection epidemiology, MTOR Inhibitors therapeutic use, Quality of Life, Exercise Tolerance, Immunosuppressive Agents therapeutic use, Tissue Preservation, Primary Graft Dysfunction epidemiology, Heart Transplantation, Heart innervation, Heart physiology
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Heart transplantation (HT) is one of the prodigious achievements in modern medicine and remains the cornerstone in the treatment of patients with advanced heart failure. Advances in surgical techniques, immunosuppression, organ preservation, infection control, and allograft surveillance have improved short- and long-term outcomes thereby contributing to greater clinical success of HT. However, prolonged allograft and patient survival following HT are still largely restricted by the development of late complications, including allograft rejection, infection, cardiac allograft vasculopathy (CAV), and malignancy. The introduction of mTOR inhibitors early after HT has demonstrated multiple protective effects against CAV progression, renal dysfunction, and tumorigenesis. Therefore, several HT programs increasingly use mTOR inhibitors with partial or complete withdrawal of calcineurin inhibitor (CNI) in stable HT patients to reduce complications risk and improve long-term outcomes. Furthermore, despite a substantial improvement in exercise capacity and health-related quality of life after HT as compared to advanced heart failure patients, most HT recipients remain with a 30% to 50% lower peak oxygen consumption (Vo
2 ) than that of age-matched healthy subjects. Several factors, including alterations in central hemodynamics, HT-related complications and alterations in the musculoskeletal system, and peripheral physiological abnormalities, presumably contribute to the reduced exercise capacity following HT. Cardiac denervation and subsequent loss of sympathetic and parasympathetic regulation are responsible for various physiological alterations in the cardiovascular system, which contributes to restricted exercise tolerance. Restoration of cardiac innervation may improve exercise capacity and quality of life, but the reinnervation process is only partial even several years after HT. Multiple studies have shown that aerobic and strengthening exercise interventions improve exercise capacity by increasing maximal heart rate, chronotropic response, and peak Vo2 after HT. Novel exercise modalities, such as high-intensity interval training (HIT), have been proven as safe and effective for further improvement in exercise capacity, including among de novo HT recipients. Further developments have recently emerged, including donor heart preservation techniques, noninvasive CAV and rejection surveillance methods, and improvements in immunosuppressive therapies, all aiming at increasing donor availability and improving late survival after HT. © 2023 American Physiological Society. Compr Physiol 13:4719-4765, 2023., (Copyright © 2023 American Physiological Society. All rights reserved.)- Published
- 2023
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22. Effect of Dapagliflozin Versus Empagliflozin on Cardiovascular Death in Patients with Heart Failure Across the Spectrum of Ejection Fraction: Cost per Outcome Analysis.
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Alnsasra H, Tsaban G, Solomon A, Khalil F, Aboalhasan E, Weinstein JM, Azuri J, Hammerman A, and Arbel R
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- Humans, Benzhydryl Compounds therapeutic use, Stroke Volume, Heart Failure drug therapy, Cardiovascular System
- Abstract
Background: Dapagliflozin and empagliflozin have shown clinical benefits in patients with heart failure (HF). Their comparative monetary value remains undetermined, and we therefore sought to compare the cost-per-outcome implications of utilizing dapagliflozin versus empagliflozin to prevent cardiovascular death (CVD) in patients with HF across the spectrum of ejection fraction., Methods: We estimated the cost needed to treat (CNT) to prevent one CVD with either dapagliflozin or empagliflozin. CNT was estimated by multiplying the annualized number needed to treat (aNNT) by the annual cost of therapy. The aNNTs were calculated based on data from the DAPA-HF and DELIVER trials for dapagliflozin, and the EMPEROR-Reduced and EMPEROR-Preserved trials for empagliflozin. Drug costs were calculated as 75% of the 2022 US National Average Drug Acquisition Cost., Results: The aNNT to prevent one event of CVD was 110 (95% confidence interval [CI] 58-∞) for dapagliflozin in a pooled analysis of DAPA-HF and DELIVER versus 204 (95% CI 71-∞) for empagliflozin in a pooled analysis of the EMPEROR-Reduced and EMPEROR-Preserved trials. The annual costs of therapy were $4807 and $4992, respectively. The corresponding CNTs were $528,770 (95% CI $278,806-∞) for dapagliflozin and $1,018,368 (95% CI $354,432-∞) for empagliflozin. This remained consistent in Europe, using the price estimates in Germany, with CNT (€77,490 for dapagliflozin and €143,708 for empagliflozin)., Conclusion: In incorporating data from all four outcomes trials of sodium-glucose cotransporter 2 inhibitors, dapagliflozin provides better monetary value for preventing CVD events in patients with HF across the spectrum of ejection fraction., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)
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- 2023
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23. Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice.
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Khalil F, Asleh R, Perue RK, Weinstein JM, Solomon A, Betesh-Abay B, Briasoulis A, and Alnsasra H
- Abstract
Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.
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- 2023
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24. Nonobstructive coronary atherosclerosis is associated with adverse prognosis among patients diagnosed with myocardial infarction without obstructive coronary arteries.
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Tsaban G, Peles I, Barrett O, Abramowitz Y, Shmueli H, Alnsasra H, Cafri C, Zahger D, and Koifman E
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- Humans, Female, Middle Aged, Aged, Male, Retrospective Studies, MINOCA, Prognosis, Coronary Angiography, Risk Factors, Coronary Artery Disease diagnosis, Myocardial Infarction
- Abstract
Background and Aims: The prognostic impact of nonobstructive coronary artery disease (CAD), as opposed to normal coronary arteries, on long-term outcomes of patients with myocardial infarction with no obstructive coronary arteries (MINOCA) is unclear. We aimed to address the association between nonobstructive-CAD and major adverse events (MAE) following MINOCA., Methods: We conducted a retrospective cohort study of consecutive MINOCA patients admitted to a large referral medical center between 2005 and 2018. Patients were classified according to coronary angiography as having either normal-coronaries or nonobstructive-CAD. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS)., Results: Of the 1544 MINOCA patients, 651 (42%) had normal coronaries, and 893 (58%) had CAD. The mean age was 61.2 ± 12.6 years, and 710 (46%) were females. Nonobstructive-CAD patients were older and less likely to be females, with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal-failure (p < 0.05). At a median follow-up of 7 years, MAE occurred in 203 (23%) patients and 67 (10%) patients in the nonobstructive-CAD and normal-coronaries groups, respectively (p < 0.01). In multivariable models, nonobstructive -CAD was significantly associated with long-term MAE [adjusted-hazard-ratio (aHR):1.67, 95% confidence-interval (95%CI):1.25-2.23; p < 0.001]. Other factors associated with a higher MAE-risk were older-age (aHR:1.05,95%CI:1.03-1.06; p < 0.001) and left ventricular ejection-fraction<40% (aHR:3.04,95%CI:2.03-4.57; p < 0.001), while female-sex (aHR:0.72, 95%CI: 0.56-0.94; p=0.014) and sinus rhythm at presentation (aHR:0.66, 95%CI: 0.44-0.98; p=0.041) were associated with lower MAE-risk., Conclusions: In MINOCA, nonobstructive-CAD is independently associated with a higher MAE-risk than normal-coronaries. This finding may promote risk-stratification of patients with nonobstructive-CAD-MINOCA who require tighter medical follow-up and treatment optimization., Competing Interests: Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)
- Published
- 2023
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25. Aspirin with Low-Dose Ticagrelor or with Low-Dose Rivaroxaban for Secondary Prevention: A Cost per Outcome Analysis.
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Tsaban G, Alnsasra H, El Nasasra A, Abu-Salman A, Abu-Dogosh A, Weissberg I, Golan YB, Barrett O, Westreich R, Aboalhasan E, Azuri J, Hammerman A, and Arbel R
- Subjects
- Humans, Ticagrelor therapeutic use, Rivaroxaban therapeutic use, Purinergic P2Y Receptor Antagonists therapeutic use, Adenosine therapeutic use, Secondary Prevention, Drug Therapy, Combination, Treatment Outcome, Platelet Aggregation Inhibitors therapeutic use, Aspirin therapeutic use, Myocardial Infarction drug therapy
- Abstract
Introduction: Secondary prevention of cardiovascular events among patients with diagnosed cardiovascular disease and high ischemic risk poses a significant challenge in clinical practice. The combinations of aspirin with low-dose (LD) ticagrelor or LD rivaroxaban have shown superiority in preventing major adverse cardiovascular events (MACE) compared with aspirin treatment alone. The comparative value for money of these two regimens remains unexplored., Methods: We analyzed each regimen's annual cost needed to treat (CNT) by multiplying the annualized number needed to treat (aNNT) by the annual cost of each drug. The aNNTs were based on outcome data from PEGASUS TIMI-54 and COMPASS trials. Scenario analyses were performed to overcome variances in terms of population risk. Costs were calculated as 75% of US National Average Drug Acquisition Cost (NADAC), extracted in January 2022. The primary outcome was defined as CNT to prevent one MACE across the two regimens. Secondary value analysis was performed for myocardial infarction (MI), stroke, and cardiovascular death as separate outcomes., Results: The aNNTs to prevent MACE with LD ticagrelor and with LD rivaroxaban were 229 [95% confidence interval (CI) 141-734] and 147 (95% CI 104-252), respectively. At an annual cost of US$3726 versus US$4533, the corresponding CNTs were US$853,254 (95% CI 525,366-2,734,884) with LD ticagrelor and US$666,351 (95% CI 471,432-1,142,316) with LD rivaroxaban., Conclusion: Combining aspirin with LD rivaroxaban provides better value for money than with LD ticagrelor for secondary prevention of MACE., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)
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- 2022
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26. Characteristics, Predictors, and Outcomes of Early mTOR Inhibitor Use After Heart Transplantation: Insights From the UNOS Database.
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Kampaktsis PN, Doulamis IP, Asleh R, Makri E, Kalamaras I, Papastergiopoulos C, Emfietzoglou M, Drosou A, Alnsasra H, Duque ER, and Briasoulis A
- Subjects
- Graft Rejection epidemiology, Graft Rejection prevention & control, Humans, Immunosuppressive Agents pharmacology, MTOR Inhibitors, TOR Serine-Threonine Kinases, Heart Transplantation adverse effects, Kidney Transplantation, Skin Neoplasms
- Abstract
Background The clinical characteristics of mTOR (mammalian target of rapamycin) inhibitors use in heart transplant recipients and their outcomes have not been well described. Methods and Results We compared patients who received mTOR inhibitors within the first 2 years after heart transplantation to patients who did not by inquiring the United Network for Organ Sharing (UNOS) database between 2010 and 2018. The primary end point was all-cause mortality with retransplantation as a competing event. Rejection, malignancy, hospitalization for infection, and renal transplantation were secondary end points. There were 1619 (9%) and 15 686 (81%) mTOR inhibitors+ and mTOR inhibitors- patients, respectively. Body mass index, induction, cardiac allograft vasculopathy, calculated panel reactive antibody, and fewer days in 1A status were independently associated with mTOR inhibitors+ status. Over a follow-up of 10.4 years, there was no difference in all-cause mortality after adjusting for donor and recipient characteristics (adjusted subdistribution hazard ratio, 1.03 [0.90-1.19]; P =0.66). mTOR inhibitors+ were independently associated with increased risk for rejection (odds ratio [OR], 1.43 [1.11-1.83]; P =0.005) and basal skin cancer (OR, 1.35 [1.19-1.51]; P =0.012) but not for infection or renal transplantation. Conclusions mTOR inhibitors are used in <10% patients in the first 2 years after heart transplantation and are noninferior to contemporary immunosuppression regimens in terms of all-cause mortality, infection, malignancy, or renal transplantation. They are associated with risk for rejection.
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- 2022
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27. Embolisation of a prosthetic mitral valve fragment during valve-in-valve transcatheter mitral valve implantation.
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Alnsasra H, Koifman E, Abu-Salman A, Kobal SL, and Cafri C
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- Cardiac Catheterization adverse effects, Humans, Mitral Valve diagnostic imaging, Mitral Valve surgery, Treatment Outcome, Heart Valve Prosthesis, Heart Valve Prosthesis Implantation adverse effects, Mitral Valve Insufficiency diagnostic imaging, Mitral Valve Insufficiency surgery
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- 2022
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28. Outcomes after heart transplantation in patients with cardiac sarcoidosis.
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Asleh R, Briasoulis A, Doulamis I, Alnsasra H, Tzani A, Alvarez P, Kuno T, Kampaktsis P, and Kushwaha S
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- Adult, Humans, Retrospective Studies, Treatment Outcome, Cardiomyopathy, Restrictive, Heart Transplantation adverse effects, Sarcoidosis complications, Sarcoidosis diagnosis, Sarcoidosis epidemiology
- Abstract
Background: The number of patients with sarcoidosis requiring heart transplantation (HT) is increasing. The aim of this study was to evaluate outcomes of isolated HT in patients with sarcoid cardiomyopathy and compare them to recipients with non-ischaemic restrictive or dilated cardiomyopathy., Methods and Results: Adult HT recipients were identified in the UNOS Registry between 1990 and 2020. Patients were grouped according to diagnosis. The cumulative incidences for the all-cause mortality and rejection were compared using Fine and Gray model analysis, accounting for re-transplantation as a competing risk. Rejection was evaluated using logistic regression analysis. We also reviewed characteristics and outcomes of all HT recipients with previous diagnosis of sarcoid cardiomyopathy from a single centre. A total of 30 160 HT recipients were included in the present study (n = 239 sarcoidosis, n = 1411 non-ischaemic restrictive cardiomyopathy, and n = 28 510 non-ischaemic dilated cardiomyopathy). During a total of 194 733 patient-years, all-cause mortality at the latest follow-up was not significantly different when comparing sarcoidosis to non-ischaemic dilated cardiomyopathy [adjusted subhazard ratio (aSHR) 1.46, 95% confidence intervals (CIs): 0.9-2.4, P = 0.12] or restrictive cardiomyopathy (aSHR 1.12, 95% CI: 0.65-1.95, P = 0.67). Accordingly, multivariable analysis suggested that 1 year mortality was not significantly different between sarcoidosis and non-ischaemic dilated cardiomyopathy (aSHR 1.56, 95% CI: 0.9-2.7, P = 0.12) or restrictive cardiomyopathy (aSHR 1.15, 95% CI: 0.61-2.18, P = 0.66). No differences were observed regarding 30 day mortality, treated and hospitalized acute rejection, and 30 day death from graft failure after HT. Thirty-day mortality did not improve significantly in more recent HT eras whereas there was a trend towards improved 1 year mortality in the latest HT era (P = 0.06). Data from the single-centre case review showed excellent long-term outcomes with sirolimus-based immunosuppression., Conclusions: Short-term and long-term post HT outcomes among patients with sarcoid cardiomyopathy are similar to those with common types of non-ischaemic cardiomyopathy., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)
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- 2022
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29. Identifying patients with atrial fibrillation with a single CHA 2 DS 2 -VASC risk factor who are at higher risk of stroke.
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Arnson Y, Senderey AB, Hoshen M, Reges O, Balicer R, Alnsasra H, Leibowitz M, Tsadok MA, and Haim M
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- Adult, Aged, Anticoagulants therapeutic use, Female, Humans, Male, Middle Aged, Retrospective Studies, Risk Assessment, Risk Factors, Young Adult, Atrial Fibrillation complications, Atrial Fibrillation epidemiology, Stroke epidemiology, Stroke etiology
- Abstract
Aims: Management of patients with a single CHA
2 DS2 -VASc score risk factor is controversial. We attempt to identify the "truly low risk" AF patients who will not benefit from oral anticoagulation (OAC) treatment., Methods: Retrospective cohort analysis, all incident non-valvular AF (NVAF) cases between 2004 and 2015, and age 21 and older, with up to one thromboembolic risk factor besides sex (CHA2 DS2 -VASc score of up to 1 for men and up to 2 for women). A "low risk" score was created for these patients using a logistic regression model on the incidence of stroke within 30-2500 days following the NVAF diagnosis., Results: We identified 15,621 patients. Average age was 53.7 ± 12.3 years, 56.6% male. Mean follow-up was 5.5 years. Significant predictors of ischemic stroke were age 65-74 and diabetes (2 points each), hypertension, vascular disease, and chronic kidney disease stage 2-3 (1 point each). Stroke incidence ranged from 0.8% for score 0 and up to 3.4% for scores ≤ 2. Odds ratio for stroke among patient group with a score ≤ 2 was 4.3 (2.9-6.6) compared with score 0. Our risk score's area-under-the-curve (AUC) for prediction of stroke was 0.68 (0.65-0.71), compared with 0.60 (0.57-0.62) for the CHAD2 S2 -VASc score, within this low-risk group., Conclusion: Patients considered at low or intermediate risk using traditional risk stratification schemes, with ≥ 2 points using this proposed low-risk index (65-74 years old, diabetics or a combination of chronic renal failure and an additional risk factor), had an overall stroke risk that may justify anticoagulation therapy., (© 2021. Royal Academy of Medicine in Ireland.)- Published
- 2022
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30. Post-transplant Lymphoproliferative Disorder Following Cardiac Transplantation.
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Asleh R, Alnsasra H, Habermann TM, Briasoulis A, and Kushwaha SS
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Post-transplant lymphoproliferative disorder (PTLD) is a spectrum of lymphoid conditions frequently associated with the Epstein Barr Virus (EBV) and the use of potent immunosuppressive drugs after solid organ transplantation. PTLD remains a major cause of long-term morbidity and mortality following heart transplantation (HT). Epstein-Barr virus (EBV) is a key pathogenic driver in many PTLD cases. In the majority of PTLD cases, the proliferating immune cell is the B-cell, and the impaired T-cell immune surveillance against infected B cells in immunosuppressed transplant patients plays a key role in the pathogenesis of EBV-positive PTLD. Preventive screening strategies have been attempted for PTLD including limiting patient exposure to aggressive immunosuppressive regimens by tailoring or minimizing immunosuppression while preserving graft function, anti-viral prophylaxis, routine EBV monitoring, and avoidance of EBV seromismatch. Our group has also demonstrated that conversion from calcineurin inhibitor to the mammalian target of rapamycin (mTOR) inhibitor, sirolimus, as a primary immunosuppression was associated with a decreased risk of PTLD following HT. The main therapeutic measures consist of immunosuppression reduction, treatment with rituximab and use of immunochemotherapy regimens. The purpose of this article is to review the potential mechanisms underlying PTLD pathogenesis, discuss recent advances, and review potential therapeutic targets to decrease the burden of PTLD after HT., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Asleh, Alnsasra, Habermann, Briasoulis and Kushwaha.)
- Published
- 2022
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31. Incidence, Risk Factors, and Outcomes of Stroke Following Cardiac Transplantation.
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Alnsasra H, Asleh R, Kumar N, Lopez C, Toya T, Kremers WK, Edwards B, Daly RC, and Kushwaha SS
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- Adult, Aged, Calcineurin Inhibitors therapeutic use, Female, Humans, Immunosuppressive Agents therapeutic use, Incidence, Male, Middle Aged, Postoperative Complications epidemiology, Postoperative Complications etiology, Retrospective Studies, Risk Factors, Sirolimus therapeutic use, Heart Transplantation adverse effects, Immunosuppression Therapy methods, Stroke epidemiology, Stroke etiology
- Abstract
Background and Purpose: Less is known about the risk factors and outcomes associated with stroke in the current era of increasing heart transplantation (HT) being performed in older patients. The impact of immunosuppression on risk of stroke has not yet been previously studied. We aimed to determine the incidence, risk factors and outcomes of stroke after HT., Methods: We retrospectively analyzed the incidence of ischemic and hemorrhagic strokes and associated outcomes in all consecutive HT recipients transplanted between 1994 and 2016 at a single institution., Results: Of 529 patients who underwent HT, 57 (10.7%) developed stroke, 8.1% had an ischemic events and (2.6%) had a hemorrhagic stroke. Age at HT (adjusted hazard ratio [HR] 1.33; P=0.03) and diabetes (HR, 2.60; P=0.02) were associated with increased risk of ischemic events. Patients with stroke (any type) were more likely to have worse kidney function (HR, 1.81; P=0.02) whereas patients with ischemic events were more likely to undergo combined organ transplantation (HR, 2.01; P=0.05). Cytomegalovirus infection was found to be associated with increased risk of any stroke (HR, 2.09; P=0.02).Conversion from calcineurin inhibitor to sirolimus-based immunosuppression was not found to be associated with a significant change in stroke risk (HR, 1.39; P=0. 45) compared with calcineurin inhibitor maintenance therapy. Stroke of any type and ischemic events were independently associated with increased risk of death (HR, 1.90; P=0.001 and HR, 2.14; P<0.001, respectively)., Conclusions: Stroke after HT is associated with increased mortality. Older age at HT, diabetes, renal dysfunction, and CMV infection were associated with greater risk of stroke.
- Published
- 2021
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32. Tricuspid valve injury after heart transplantation: how to monitor for rejection?
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Guo A, Alnsasra H, Kitahara H, Rodrigo M, and Medvedofsky D
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- Humans, Tricuspid Valve diagnostic imaging, Tricuspid Valve surgery, Heart Transplantation adverse effects, Heart Valve Prosthesis, Tricuspid Valve Insufficiency diagnostic imaging, Tricuspid Valve Insufficiency etiology, Tricuspid Valve Insufficiency surgery
- Published
- 2021
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33. Mitral inflow obstruction by a descending thoracic aortic aneurysm.
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Alnsasra H, Goldstein SA, and Chang IC
- Subjects
- Aorta, Thoracic, Blood Vessel Prosthesis, Humans, Aortic Aneurysm, Thoracic diagnostic imaging, Aortic Aneurysm, Thoracic surgery
- Published
- 2021
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34. Association of Aspirin Treatment With Cardiac Allograft Vasculopathy Progression and Adverse Outcomes After Heart Transplantation.
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Asleh R, Briasoulis A, Smith B, Lopez C, Alnsasra H, Pereira NL, Edwards BS, Clavell AL, Stulak JM, Locker C, Kremers WK, Daly RC, Lerman A, and Kushwaha SS
- Subjects
- Allografts, Aspirin therapeutic use, Coronary Angiography, Humans, Retrospective Studies, Coronary Artery Disease, Heart Failure, Heart Transplantation adverse effects
- Abstract
Background: Enhanced platelet reactivity may play a role in cardiac allograft vasculopathy (CAV) progression. The use of antiplatelet agents after heart transplantation (HT) has been inconsistent and although aspirin (ASA) is often a part of the medication regimen after HT, limited evidence is available on its benefit., Methods and Results: CAV progression was assessed by measuring the difference in plaque volume and plaque index between the last follow-up and the baseline coronary intravascular ultrasound examination. Overall, 529 HT recipients were retrospectively analyzed (337 had ≥2 intravascular ultrasound studies). The progression in plaque volume (P = .007) and plaque index (P = .002) was significantly attenuated among patients treated with early ASA (within the first year after HT). Over a 6.7-year follow-up, all-cause mortality was lower with early ASA compared with late or no ASA use (P < .001). No cardiac deaths were observed in the early ASA group, and the risk of CAV-related graft dysfunction was significantly lower in this group (P = .03). However, the composite of all CAV-related events (cardiac death, CAV-related graft dysfunction, or coronary angioplasty) was not significantly different between the groups (P = .16)., Conclusions: Early ASA use after HT may delay CAV progression and decrease mortality and CAV-related graft dysfunction, but does not seem to affect overall CAV-associated events., (Copyright © 2021 Elsevier Inc. All rights reserved.)
- Published
- 2021
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35. Pericardiocentesis induced right ventricular changes in patients with and without pulmonary hypertension.
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Alnsasra H, Case BC, Yang M, Rogers T, Satler LF, Asch FM, Waksman R, Kumar P, Ben-Dor I, and Medvedofsky D
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- Echocardiography, Heart Ventricles diagnostic imaging, Humans, Pericardiocentesis, Ventricular Function, Right, Hypertension, Pulmonary complications, Hypertension, Pulmonary diagnostic imaging, Ventricular Dysfunction, Right diagnostic imaging, Ventricular Dysfunction, Right etiology
- Abstract
Background: Pericardial effusion drainage in patients with significant pulmonary hypertension (PH) has been questioned because of hemodynamic collapse concern, mainly because of right ventricular (RV) function challenging assessment. We aimed to assess RV function changes related to pericardiocentesis in patients with and without PH., Methods: Consecutive patients with symptomatic moderate-to-large pericardial effusion who had either echocardiographic or clinical signs of cardiac tamponade and who underwent pericardiocentesis from 2013 to 2018 were included. RV speckle-tracking echocardiography analysis was performed before and after pericardiocentesis. Patients were stratified by significant PH (pulmonary artery systolic pressure [PASP] ≥50 mm Hg)., Results: The study cohort consisted of 76 patients, 23 (30%) with PH. In patients with PH, both end-diastolic and end-systolic areas (EDA, ESA) increased significantly after pericardiocentesis (22.6 ± 8.0 cm
2 -26.4 ± 8.4 cm2 , P = .01) and (15.9 ± 6.3 cm2 -18.7 ± 6.5 cm2 , P = .02), respectively. However, RV function indices including fractional area change (FAC: 30.6 ± 13.7%-29.1 ± 8.8%, P = .61) and free-wall longitudinal strain (FWLS: -16.7 ± 6.7 to -15.9 ± 5.0, P = .50) remained unchanged postpericardiocentesis. In contrast, in the non-PH group, after pericardiocentesis, EDA increased significantly (20.4 ± 6.2-22.4 ± 5.9 cm2 , P = .006) but ESA did not (14.9 ± 5.7 vs 15.0 ± 4.6 cm2 , P = .89), and RV function indices improved (FAC 27.9 ± 11.7%-33.1 ± 8.5%, P = .003; FWLS -13.6 ± 5.4 to -17.2 ± 3.9%, P < .001)., Conclusion: Quantification of RV size and function can improve understanding of echocardiographic and hemodynamic changes postpericardiocentesis, which has the potential to guide management of PH patients with large pericardial effusion., (© 2021 Wiley Periodicals LLC.)- Published
- 2021
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36. Comparison of Outcomes with or without Beta-Blocker Therapy After Acute Myocardial Infarction in Patients Without Heart Failure or Left Ventricular Systolic Dysfunction (from the Acute Coronary Syndromes Israeli Survey [ACSIS]).
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El Nasasra A, Beigel R, Klempfner R, Alnsasra H, Matetzky S, Iakobishvili Z, Rubinshtein R, Halabi M, Blatt A, and Zahger D
- Subjects
- Aged, Echocardiography, Female, Humans, Ischemic Stroke epidemiology, Israel epidemiology, Male, Middle Aged, Mortality, Multivariate Analysis, Myocardial Infarction drug therapy, Myocardial Infarction epidemiology, Myocardial Ischemia epidemiology, Myocardial Revascularization statistics & numerical data, Percutaneous Coronary Intervention, Recurrence, Stroke Volume, Adrenergic beta-Antagonists therapeutic use, Non-ST Elevated Myocardial Infarction drug therapy, ST Elevation Myocardial Infarction drug therapy
- Abstract
The contemporary benefit of routine beta-blocker therapy following myocardial infraction in the absence of heart failure or left ventricular systolic dysfunction is unclear. We investigated the impact of beta-blockers on post myocardial infarction outcome in patients without heart failure or left ventricular systolic dysfunction among patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys. MACE rates at 30 days and overall mortality at one year were compared among patients discharged on beta-blockers versus not, after multivariate analysis to adjust for baseline differences. Between the years 2000 to 2016, data from 15.211consecutive ACS patients were collected. Of 7,392 patients who met the inclusion criteria, 6007 (79.9%) were discharged on beta-blocker therapy. Prescription of beta-blockers at discharge increased modestly from 32% to 38% over the 16-year period. The 30-day MACE rates were similar in patients on vs. not on beta-blockers at discharge (9.0% and 9.5%, respectively). One year survival did not differ significantly between those on vs. not on beta-blockers (HR 0.8, 95% CI 0.58 to 1.11, p = 0.18).In conclusion, beta-blocker therapy did not affect 30 days MACE or 1-year survival after myocardial infarction in patients without heart failure or reduced ejection fraction., (Copyright © 2020 Elsevier Inc. All rights reserved.)
- Published
- 2021
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37. Effects of mTOR inhibitor-related proteinuria on progression of cardiac allograft vasculopathy and outcomes among heart transplant recipients.
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Asleh R, Alnsasra H, Lerman A, Briasoulis A, Pereira NL, Edwards BS, Toya T, Stulak JM, Clavell AL, Daly RC, and Kushwaha SS
- Subjects
- Allografts, Humans, Proteinuria, TOR Serine-Threonine Kinases, Heart Transplantation adverse effects, Immunosuppressive Agents adverse effects
- Abstract
We have previously described the use of sirolimus (SRL) as primary immunosuppression following heart transplantation (HT). The advantages of this approach include attenuation of cardiac allograft vasculopathy (CAV), improvement in glomerular filtration rate (GFR), and reduced malignancy. However, in some patients SRL may cause significant proteinuria. We sought to investigate the prognostic value of proteinuria after conversion to SRL. CAV progression and adverse clinical events were studied. CAV progression was assessed by measuring the Δ change in plaque volume (PV) and plaque index (PI) per year using coronary intravascular ultrasound. Proteinuria was defined as Δ urine protein ≥300 mg/24 h at 1 year after conversion to SRL. Overall, 137 patients were analyzed (26% with proteinuria). Patients with proteinuria had significantly lower GFR (P = .005) but similar GFR during follow-up. Delta PV (P < .001) and Δ PI (P = .001) were significantly higher among patients with proteinuria after adjustment for baseline characteristics. Multivariate Cox regression analysis showed higher all-cause mortality (hazard ratio 3.8; P = .01) with proteinuria but similar risk of CAV-related events (P = .61). Our results indicate that proteinuria is a marker of baseline renal dysfunction, and that HT recipients who develop proteinuria after conversion to SRL have less attenuation of CAV progression and higher mortality risk., (© 2020 The American Society of Transplantation and the American Society of Transplant Surgeons.)
- Published
- 2021
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38. Impact of Sirolimus as a Primary Immunosuppressant on Myocardial Fibrosis and Diastolic Function Following Heart Transplantation.
- Author
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Alnsasra H, Asleh R, Oh JK, Maleszewski JJ, Lerman A, Toya T, Chandrasekaran K, Bois MC, and Kushwaha SS
- Subjects
- Biopsy methods, Cardiac Catheterization methods, Echocardiography methods, Female, Fibrosis etiology, Fibrosis pathology, Fibrosis prevention & control, Heart Failure, Diastolic diagnosis, Heart Failure, Diastolic etiology, Heart Failure, Diastolic prevention & control, Humans, Immunosuppressive Agents administration & dosage, Immunosuppressive Agents adverse effects, Male, Middle Aged, Retrospective Studies, Calcineurin Inhibitors administration & dosage, Calcineurin Inhibitors adverse effects, Cardiomyopathies etiology, Cardiomyopathies pathology, Cardiomyopathies physiopathology, Heart Transplantation adverse effects, Heart Transplantation methods, Myocardium pathology, Sirolimus administration & dosage, Sirolimus adverse effects
- Abstract
Background Myocardial fibrosis is an important contributor for development of diastolic dysfunction. We investigated the impact of sirolimus as primary immunosuppression on diastolic dysfunction and fibrosis progression among heart transplantation recipients. Methods and Results In 100 heart transplantation recipients who were either treated with a calcineurin inhibitor (CNI) (n=51) or converted from CNI to sirolimus (n=49), diastolic function parameters were assessed using serial echocardiograms and right heart catheterizations. Myocardial fibrosis was quantified on serial myocardial biopsies. After 3 years, lateral e' increased within the sirolimus group but decreased in the CNI group (0.02±0.04 versus -0.02±0.04 m/s delta change; P =0.003, respectively). Both pulmonary capillary wedge pressure and diastolic pulmonary artery pressure significantly decreased in the sirolimus group but remained unchanged in the CNI group (-1.50±2.59 versus 0.20±2.20 mm Hg/year; P =0.02; and -1.72±3.39 versus 0.82±2.59 mm Hg/year; P =0.005, respectively). A trend for increased percentage of fibrosis was seen in the sirolimus group (8.48±3.17 to 10.10±3.0%; P =0.07) as compared with marginally significant progression in the CNI group (8.76±3.87 to 10.56±4.34%; P =0.04). The percent change in fibrosis did not differ significantly between the groups (1.62±4.67 versus 1.80±5.31%, respectively; P =0.88). Conclusions Early conversion to sirolimus is associated with improvement in diastolic dysfunction and filling pressures as compared with CNI therapy. Whether this could be attributed to attenuation of myocardial fibrosis progression with sirolimus treatment warrants further investigation.
- Published
- 2021
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39. Rare Case of Coincident Quadricuspid Pulmonic Valve and Suprapulmonic Ridge: Multimodality Imaging.
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Guo A, Alnsasra H, Medvedofsky D, Najjar SS, and Srichai MB
- Abstract
A 32-year-old woman with a history of mild congenital pulmonic stenosis presented with new dyspnea on exertion. Multimodal imaging revealed a quadricuspid pulmonic valve with supravalvular ridge. We illustrate the evaluation and diagnosis of this rare condition. ( Level of Difficulty: Advanced. )., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2020 The Authors.)
- Published
- 2020
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40. Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation With Continuous-Flow Left Ventricular Assist Devices.
- Author
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Asleh R, Alnsasra H, Daly RC, Schettle SD, Briasoulis A, Taher R, Dunlay SM, Stulak JM, Behfar A, Pereira NL, Frantz RP, Edwards BS, Clavell AL, and Kushwaha SS
- Subjects
- Adult, Age Factors, Aged, Cardiomyopathy, Dilated complications, Cardiopulmonary Bypass statistics & numerical data, Cause of Death, Comorbidity, Creatinine blood, Female, Heart Defects, Congenital complications, Heart Failure etiology, Humans, Kidney Transplantation statistics & numerical data, Liver Transplantation statistics & numerical data, Logistic Models, Male, Middle Aged, Mortality, Multivariate Analysis, Myocardial Ischemia complications, Operative Time, Proportional Hazards Models, Risk Factors, Survival Rate, Thyroid Diseases epidemiology, Time Factors, Heart Failure therapy, Heart Transplantation, Heart-Assist Devices, Postoperative Complications epidemiology, Vasoplegia epidemiology
- Abstract
Background The presence of a durable left ventricular assist device (LVAD) is associated with increased risk of vasoplegia in the early postoperative period following heart transplantation (HT). However, preoperative predictors of vasoplegia and its impact on survival after HT are unknown. We sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with an LVAD. Methods and Results We identified 94 patients who underwent HT after bridging with continuous-flow LVAD from 2008 to 2018 at a single institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours after HT for >24 hours to maintain mean arterial pressure >70 mm Hg. Overall, 44 patients (46.8%) developed vasoplegia after HT. Patients with and without vasoplegia had similar preoperative LVAD, echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older; had longer LVAD support, higher preoperative creatinine, longer cardiopulmonary bypass time, and higher Charlson comorbidity index; and more often underwent combined organ transplantation. In a multivariate logistic regression model, older age (odds ratio: 1.08 per year; P =0.010), longer LVAD support (odds ratio: 1.06 per month; P =0.007), higher creatinine (odds ratio: 3.9 per 1 mg/dL; P =0.039), and longer cardiopulmonary bypass time (odds ratio: 1.83 per hour; P =0.044) were independent predictors of vasoplegia. After mean follow-up of 4.0 years after HT, vasoplegia was associated with increased risk of all-cause mortality (hazard ratio: 5.20; 95% CI, 1.71-19.28; P =0.003). Conclusions Older age, longer LVAD support, impaired renal function, and prolonged intraoperative CPB time are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with worse prognosis; therefore, detailed assessment of these predictors can be clinically important.
- Published
- 2019
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41. Feasibility and safety of exclusive echocardiography-guided intravenous temporary pacemaker implantation.
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El Nasasra A, Alnsasra H, Zahger D, Lerman TT, Kobal S, Cafri C, Haim M, Fuchs L, and Shimony A
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- Aged, Aged, 80 and over, Atrioventricular Block therapy, Case-Control Studies, Emergencies, Feasibility Studies, Female, Fluoroscopy methods, Heart Arrest therapy, Humans, Male, Middle Aged, Point-of-Care Systems, Retrospective Studies, Sick Sinus Syndrome therapy, Surgery, Computer-Assisted, Tachycardia, Ventricular therapy, Torsades de Pointes therapy, Arrhythmias, Cardiac therapy, Cardiac Catheterization methods, Echocardiography methods, Pacemaker, Artificial, Prosthesis Implantation methods
- Abstract
Background: The standard approach for urgent trans-venous temporary cardiac pacemaker (TVTP) implantation is fluoroscopy guidance. The delay in activation of the fluoroscopy-room and the transfer of unstable patients may be life-threatening. Echocardiography-guided TP implantation may increase the safety of the patients by obviating the need for in-hospital transfer. We examined the feasibility and safety of echocardiography-guided vs. fluoroscopy-guided TVTP implantation., Methods: From January 2015 to September 2017 data for consecutive patients who needed emergent TVTP implantation were retrospectively reviewed. Ultrasound-guided TVTP protocol that was introduced in our center in January 2015 involved ultrasound guidance for both central venous access and pacing lead positioning. Access sites included femoral, subclavian, or jugular veins. Electrodes were placed in the right ventricular apex by means of echocardiographic monitoring in intensive care unit or by fluoroscopic guidance. Endpoints were achievement of successful ventricular pacing and procedural complications., Results: Sixty-six patients (17 echocardiography-guided and 49 fluoroscopy-guided) were included. There were no differences in pacing threshold between the echocardiography-guided group and the fluoroscopy-guided group (0.75 ± 0.58 mA vs. 0.57 ± 0.35 mA, p = 0.24). The access site for implantation was femoral vein in 27% for the fluoroscopy-guided vs. none for the echocardiography-guided approach (p = 0.015). One hematoma and one related infection occurred in the fluoroscopy-guided group. The need for electrode repositioning was observed in 1 patient in each group. There were no procedural-related deaths in either group., Conclusions: Echocardiography-guided temporary cardiac pacing is a feasible and safe alternative to fluoroscopy-guided approach and significantly lowers the need for in-hospital transfer.
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- 2019
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42. Diastolic Pulmonary Gradient as a Predictor of Right Ventricular Failure After Left Ventricular Assist Device Implantation.
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Alnsasra H, Asleh R, Schettle SD, Pereira NL, Frantz RP, Edwards BS, Clavell AL, Maltais S, Daly RC, Stulak JM, Rosenbaum AN, Behfar A, and Kushwaha SS
- Subjects
- Aged, Cardiac Catheterization, Diastole, Female, Heart Failure complications, Heart Failure physiopathology, Humans, Hypertension, Pulmonary etiology, Kaplan-Meier Estimate, Male, Middle Aged, Pressure, Prognosis, Proportional Hazards Models, Pulmonary Artery, Pulmonary Wedge Pressure, Retrospective Studies, Risk Assessment, Vascular Remodeling physiology, Vascular Resistance physiology, Ventricular Dysfunction, Left complications, Ventricular Dysfunction, Left physiopathology, Ventricular Dysfunction, Right epidemiology, Heart Failure therapy, Heart-Assist Devices, Hypertension, Pulmonary physiopathology, Ventricular Dysfunction, Left therapy, Ventricular Dysfunction, Right physiopathology
- Abstract
Background Diastolic pulmonary gradient (DPG) was proposed as a better marker of pulmonary vascular remodeling compared with pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG). The prognostic significance of DPG in patients requiring a left ventricular assist device (LVAD) remains unclear. We sought to investigate whether pre-LVAD DPG is a predictor of survival or right ventricular (RV) failure post-LVAD. Methods and Results We retrospectively reviewed 268 patients who underwent right heart catheterization before LVAD implantation from 2007 to 2017 and had pulmonary hypertension because of left heart disease. Patients were dichotomized using DPG ≥7 mm Hg, PVR ≥3 mm Hg, or TPG ≥12 mm Hg. The associations between these parameters and all-cause mortality or RV failure post LVAD were assessed with Cox proportional hazards regression and Kaplan-Meier analyses. After a mean follow-up time of 35 months, elevated DPG was associated with increased risk of RV failure (hazard ratio [HR]: 3.30; P=0.004, for DPG ≥7 versus DPG <7), whereas elevated PVR (HR 1.85, P=0.13 for PVR ≥3 versus PVR <3) or TPG (HR 1.47, P=0.35, for TPG ≥12 versus TPG <12) were not associated with the development of RV failure. Elevated DPG was not associated with mortality risk (HR 1.16, P=0.54, for DPG ≥7 versus DPG <7), whereas elevated PVR, but not TPG, was associated with higher mortality risk (HR 1.55; P=0.026, for PVR ≥3 versus PVR <3). Conclusions Among patients with pulmonary hypertension because of left heart disease requiring LVAD support, elevated DPG was associated with RV failure but not survival, while elevated PVR predicted mortality post LVAD implantation.
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- 2019
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43. Dizziness in the Heartmate III patient.
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Schettle S, Stulak J, Alnsasra H, and Clavell A
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- 2019
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44. Incidence of Malignancies in Patients Treated With Sirolimus Following Heart Transplantation.
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Asleh R, Clavell AL, Pereira NL, Smith B, Briasoulis A, Alnsasra H, Kremers WK, Habermann TM, Otley CC, Li X, Edwards BS, Stulak JM, Daly RC, and Kushwaha SS
- Subjects
- Adult, Aged, Female, Humans, Incidence, Male, Middle Aged, Minnesota epidemiology, Neoplasms chemically induced, Retrospective Studies, Skin Neoplasms chemically induced, Skin Neoplasms epidemiology, Calcineurin Inhibitors adverse effects, Heart Transplantation mortality, Immunosuppressive Agents adverse effects, Neoplasms epidemiology, Sirolimus adverse effects
- Abstract
Background: Malignancy is a major cause of late post-heart transplantation (HT) mortality. Sirolimus (SRL) exerts antiproliferative properties and its long-term use in HT as primary immunosuppression (IS) is associated with decreased mortality risk that is not fully explained by attenuation of cardiac allograft vasculopathy progression., Objectives: This study sought to examine whether conversion from calcineurin inhibitor (CNI)-based to SRL-based IS was associated with decreased risk of malignancy post-HT., Methods: Overall, 523 patients underwent HT between 1994 and 2016 at a single institution. The main outcomes included incidence of overall de novo malignancies (excluding non-melanoma skin cancers [NMSCs]), post-transplantation lymphoproliferative disorders (PTLD), and first and subsequent primary occurrences of NMSC post-HT., Results: The study identified 307 patients on SRL-based and 216 on CNI-based maintenance IS. Over a median follow-up of 10 years after HT, overall de novo malignancies (non-NMSC) occurred in 31% of CNI patients and in 13% of SRL patients (adjusted hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.18 to 0.62; p < 0.001). The incidence of the first NMSC was similar in the SRL and CNI groups (HR: 0.92; 95% CI: 0.66 to 1.28; p = 0.62). However, conversion to SRL was significantly associated with a decreased risk of subsequent primary occurrences of NMSC compared with that of CNI (adjusted HR: 0.44; 95% CI: 0.28 to 0.69; p < 0.001). The adjusted PTLD risk was significantly decreased in the SRL group (HR: 0.13; 95% CI: 0.03 to 0.59; p = 0.009). Late survival post-HT was markedly decreased in patients who developed non-NMSC, PTLD, or non-PTLD compared with patients who did not develop these malignancies, whereas NMSC had no significant effect on survival., Conclusions: Conversion to SRL was associated with a decreased risk of all de novo malignancies, PTLD, and subsequent primary occurrences of NMSC after HT. These findings provided further explanation of the late survival benefit with long-term SRL use., (Published by Elsevier Inc.)
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- 2019
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45. Net clinical benefit of anticoagulant treatments in elderly patients with nonvalvular atrial fibrillation: Experience from the real world.
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Alnsasra H, Haim M, Senderey AB, Reges O, Leventer-Roberts M, Arnson Y, Leibowitz M, Hoshen M, and Avgil-Tsadok M
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- Administration, Oral, Aged, Aged, 80 and over, Atrial Fibrillation complications, Atrial Fibrillation diagnosis, Brain Ischemia epidemiology, Brain Ischemia etiology, Dose-Response Relationship, Drug, Female, Follow-Up Studies, Humans, Incidence, Israel epidemiology, Male, Retrospective Studies, Risk Factors, Treatment Outcome, Anticoagulants administration & dosage, Atrial Fibrillation drug therapy, Brain Ischemia prevention & control, Risk Assessment methods
- Abstract
Background: Oral anticoagulation (OAC) is effective in stroke prevention in elderly patients with nonvalvular atrial fibrillation (AF), but older patients are also at higher risk of bleeding., Objective: We aimed to examine whether OAC has net clinical benefit (NCB) in elderly patients with AF., Methods: This is a retrospective cohort study of patients with AF, aged 75 years and older, who were diagnosed from January 1, 2013, through December 31, 2015. Incidences of stroke and intracranial hemorrhage (ICH) were estimated as the number of events per 100 person-years. The NCBs were estimated with respect to time in therapeutic range (TTR) (<60% or ≥60%) and treatment type (warfarin and low or high dose of direct oral anticoagulants [DOACs])., Results: We included 11,760 patients, of whom 4982 (42.4%) were treated with OACs: 2042 (17.4%) with warfarin and 2940 (25.0%) with DOACs. Among patients treated with warfarin, those who achieved TTR ≥ 60% had a lower incidence of stroke (2.54 per 100 person-years vs 5.21 per 100 person-years; P = .01) but without a statistically significant lower incidence of ICH (0.68 per 100 person-years vs 1.10 per 100 person-years; P = .45) and a higher NCB (9.78 vs 6.52) than did those with TTR < 60%. Among patients treated with DOACs, patients treated with the high dose had a statistically significant similar incidence of stroke (8.40 per 100 person-years vs 9.81 per 100 person-years; P = .67), a statistically significant lower incidence of ICH (0.33 per 100 person-years vs 1.20 per 100 person-years; P = .02), and a higher NCB (4.42 vs 1.78) than did patients treated with the low dose., Conclusion: A large proportion of elderly patients are not treated with OACs. We found that the NCB of OAC in the elderly is positive, with the highest benefit in elderly patients treated with warfarin who achieved TTR ≥ 60% or high dose of DOACs., (Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)
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- 2019
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46. High-grade atrioventricular block in patients with acute myocardial infarction. Insights from a contemporary multi-center survey.
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Alnsasra H, Ben-Avraham B, Gottlieb S, Ben-Avraham M, Kronowski R, Iakobishvili Z, Goldenberg I, Strasberg B, and Haim M
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- Aged, Atrioventricular Block mortality, Atrioventricular Block physiopathology, Atrioventricular Block therapy, Female, Hospital Mortality, Humans, Incidence, Israel epidemiology, Male, Middle Aged, Prognosis, Prospective Studies, Risk Factors, Atrioventricular Block etiology, Myocardial Infarction complications
- Abstract
High-grade atrioventricular block (HAVB) is a frequent complication of acute myocardial infarction (AMI) and is associated with increased morbidity and mortality. We aimed to evaluate the incidence, predictors, and prognostic significance of HAVB in a contemporary cohort of patients with AMI, in the recent era of early reperfusion. Patients with acute coronary syndromes (n=11,487) during the years 2000-2010 were included. Patients were divided into two groups: with HAVB (n=308, 2.7%) and without HAVB (n=11,179, 97.3%). The incidence of HAVB decreased from 4.2% in 2000 to 2.1% in 2010 (p for trend<0.01). Patients with HAVB were more likely to develop in-hospital complications. Independent predictors of developing HAVB were older age, ST-elevation myocardial infarction (STEMI), smoking and Killip class≥2 on admission. 30-day and 1-year mortality rates were significantly higher in the HAVB as compared to the non-HAVB group (24% vs. 4.9%, p<0.01, 33.5% vs. 10%, p<0.01, respectively). Multivariable logistic regression analysis revealed that, HAVB was associated with increased 30-day (OR - 3.97; 95% CI - 1.96-8.04) and 1-year mortality risk (HR - 2.02; 95% CI - 1.3-3.1). Similar estimates were obtained for STEMI and non-STEMI (NSTEMI). In conclusion, although the incidence of HAVB decreased over the last decade, the associated morbidity and mortality are still high in these patients despite early reperfusion therapy., (Copyright © 2018. Published by Elsevier Inc.)
- Published
- 2018
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47. Contemporary Determinants of Delayed Benchmark Timelines in Acute Myocardial Infarction in Men and Women.
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Alnsasra H, Zahger D, Geva D, Matetzky S, Beigel R, Iakobishvili Z, Alcalai R, Atar S, and Shimony A
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- Age Factors, Aged, Emergency Medical Services, Female, Follow-Up Studies, Humans, Israel epidemiology, Male, Middle Aged, Myocardial Infarction mortality, Prospective Studies, Risk Factors, Sex Factors, Time Factors, Benchmarking organization & administration, Hospitalization trends, Myocardial Infarction therapy, Percutaneous Coronary Intervention, Registries, Time-to-Treatment organization & administration
- Abstract
Treatment delays in patients with acute myocardial infarction (AMI) are related to increased morbidity and mortality. Hence, identifying determinants of delay may help reduce time to treatment. Importantly, limited data suggest that there may be sex-related disparities in benchmark timelines. Although guidelines advocate the use of the first medical contact (FMC) rather than hospital admission as the moment from which delays to treatment should be monitored, the latter is still often used for quality purposes. We aimed to identify factors associated with treatment delays, with an emphasis on sex-related disparities. We reviewed data on 3,658 patients with AMI from 2 contemporary, consecutive multicenter surveys. Measured delays were FMC-to-electrocardiogram >10 minutes in ST-elevation MI (STEMI) and non-STEMI, FMC-to-primary percutaneous coronary intervention >90 minutes in STEMI, and invasive angiography >72 hours after admission in non-STEMI patients. Timely electrocardiogram was performed in 48% of patients with STEMI and in 39.8% of non-STEMI patients without significant sex-related differences. Independent determinants of delay included atypical chest pain (CP) and presentation during daytime. In patients with STEMI, 37.5% had primary percutaneous coronary intervention in less than 90 minutes without significant sex-related disparities. Independent determinants of delay included atypical CP, night presentation, and diabetes. In non-STEMI patients, independent determinants of delayed invasive approach were female sex, age >75 years, atypical CP, and renal failure. In conclusion, significant treatment delays in patients with AMI are still frequent in contemporary practice, highlighting the need for improvement and guidelines implementation. Predictors of delay identified in our study may facilitate targeting of interventions to improve adherence to guidelines., (Copyright © 2017 Elsevier Inc. All rights reserved.)
- Published
- 2017
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48. Successful treatment of ventricular fibrillation storm triggered by short-long-short sequence; time to avoid managed ventricular pacing.
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Alnsasra H, Konstantino Y, Bereza S, and Haim M
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- Adult, Cardiomyopathy, Hypertrophic physiopathology, Death, Sudden, Cardiac prevention & control, Electrocardiography, Humans, Male, Cardiac Pacing, Artificial methods, Cardiomyopathy, Hypertrophic therapy, Pacemaker, Artificial, Ventricular Fibrillation physiopathology, Ventricular Fibrillation therapy
- Abstract
Sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) is caused by ventricular tachyarrhythmia that can be effectively treated by implantable cardioverter defibrillator (ICD) therapy. We report of a 28-year-old man with HCM and a dual chamber ICD, originally implanted for primary prevention of SCD, (programmed to AAI(R)-DDD(R); managed ventricular pacing (MVP) mode, Medtronic Inc. St Paul, MN USA). He presented with recurrent ICD shocks due to ventricular fibrillation (VF) despite antiarrhythmic therapy. Careful assessment of the stored electrograms demonstrated a repetitive pattern of VF initiation following short-long-short sequences. Initially, activation of ventricular rate stabilization (VRS) algorithm failed to prevent recurrent VF. Ultimately, deactivation of MVP and reprogramming the device to DDD mode with VRS on, resulted in arrhythmia suppression and avoidance of ICD shocks. Physicians should be aware that although VRS function is available in MVP mode, it does not function in the AAI mode during MVP; in order to effectively treat short-long-short sequence induced ventricular arrhythmia by device programming., (Copyright © 2017 Elsevier Inc. All rights reserved.)
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- 2017
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49. Ethnic Diversity and Increasing Resistance Patterns of Hospitalized Community-Acquired Urinary Tract Infections in Southern Israel: A Prospective Study.
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Elnasasra A, Alnsasra H, Smolyakov R, Riesenberg K, and Nesher L
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- Arabs, Community-Acquired Infections drug therapy, Community-Acquired Infections ethnology, Escherichia coli, Escherichia coli Infections drug therapy, Escherichia coli Infections ethnology, Female, Humans, Israel ethnology, Male, Prospective Studies, Urinary Tract Infections ethnology, Anti-Bacterial Agents therapeutic use, Drug Resistance, Bacterial, Urinary Tract Infections drug therapy
- Abstract
Background: Little is known about the incidence of urinary tract infections (UTI) in the dispersed Bedouin population. UTIs are routinely treated empirically according to local resistance patterns, which is important when evaluating the risk factors and antibiotic resistance patterns in the Bedouin population., Objectives: To analyze risk factors, pathogens, and antibiotic resistance patterns of UTIs in the Bedouin population compared to the general population in southern Israel. To compare data from this study to that from a previous study conducted at our center., Methods: We prospectively followed all patients hospitalized with community acquired UTIs during a 4 month period at Soroka Medical Center. We also compared results from this study to those from a study conducted in 2000., Results: The study comprised 223 patients: 44 Bedouin (19.7%), 179 (80.3) non-Bedouin; 158 female (70.9%), 65 male (29.1). The Bedouin were younger (51.7 vs. 71.1 years of age, P < 0.001) and had a lower Charlson Comorbidity Index (2.25 vs. 4.87, P < 0.001). Enterobacteriaceae were the most common pathogens identified, and Escherichia coli (E. coli) was the most common with 156 (70%) strains identified, followed by Klebsiella spp. with 29 (13%), Proteus spp. with 18 (8%), pseudomonas with 9 (4%), and other bacteria including enterococci with 11 (5%). The prevalence of E. coli increased significantly from 56% in 2000 to 70% in this study. We also noted an increase in community acquired extended spectrum beta lactamase (ESBL) pathogens from 4.5% in 2000 to 25.5% in the present study. No statistically significant difference was observed between the Bedouin and general populations in the causal pathogens, resistance to antibiotics, length of therapy, and readmission rate within 60 days., Conclusions: The Bedouin population hospitalized for UTIs is younger and presents with fewer co-morbidities. Isolated pathogens were similar to those found in the general population as was the presence of drug resistant infections. Overall, a substantial percentage of pathogens were resistant to standard first-line antibiotics, driving the need to change from empiric therapy to aminoglycoside therapy.
- Published
- 2017
50. Swallow-induced syncope and carotid sinus hypersensitivity: Coincident or associated conditions?
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Zaid EA, Haim M, Alnsasra H, and Konstantino Y
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- Aged, Electrocardiography, Esophagoscopy, Humans, Male, Pacemaker, Artificial, Syncope prevention & control, Carotid Sinus physiopathology, Esophageal Achalasia complications, Esophageal Achalasia physiopathology, Syncope etiology, Syncope physiopathology
- Abstract
Swallow induced syncope is a rare clinical condition which is thought to result from an abnormal vagal reflex leading to bradycardia and cerebral hypoperfusion. It mostly occurs in patients with organic or functional disorders of the esophagus, and often requires permanent pacemaker implantation, along with treatment of the underlying esophageal pathology. In the following case, we report of a 71-year-old male with achalasia post per oral endoscopic myectomy, who presented with syncope and documented AV-block while eating solid food. In addition, long sinus pauses were noted during carotid sinus massage, suggesting that the two distinct entities may be associated, and further supporting the mechanism of neurally mediated syncope in the pathophysiology of swallow-induced syncope., (Copyright © 2017 Elsevier Inc. All rights reserved.)
- Published
- 2017
- Full Text
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